Surgical management of chronic inguinal pain syndromes - Liespijn

evaluate if preservation or elective division of the inguinal nerves during hernia repairwould influence chronic pain 16-17 . These trials reported inconclusive results. A consecutivedouble-blind randomized controlled trial with one hundred subjects studying aprophylactic neurectomy of the ilioinguinal nerve during Lichtenstein hernia repairdemonstrated a decreased incidence of exertional chronic pain 18 . The procedure wasneither associated with more neurophysiological abnormalities nor with deteriorationin quality of life. Therefore the authors proposed prophylactic ilioinguinal neurectomyas a routine surgical step during open mesh hernia repair. From an empirical point ofview a neurectomy is advisable when the ilioinguinal nerve is at high risk of entrapmentdue to the placement of the mesh. However, larger clinical trials with a longerfollow up period are required.A standard polypropylene mesh is associated with a strong foreign body reactionresulting in the desired abdominal wall strength, but in itself may also act as a probablecause of pain 19 . Based on this hypothesis Bringman et al. assessed the impact of alightweight or standard mesh on chronic pain with a three-year follow up 20 . The use oflightweight mesh (LW) produced less chronic pain, although the reported differencewas small and only significant during palpation in the groin (standard = 3,3% vs. LW =0,8%). There was no difference in recurrence rate. However, considering increased costsof lightweight mesh, these results were not convincing in altering daily surgical practice.The issue of chronic postherniorrhaphy pain has created the dilemma if surgery shouldalways be the preferential treatment in patients with absent or mild symptoms. In apublished series of 323 operated patients, those who graded their pre-operative pain asmoderate or severe benefited the most of their hernia repair, which is in contrast tothose patients who had no pain at rest before operation 4 . These latter patients hadsignificant pain scores at 1 year. Overall five percent of the total study group gradedtheir present pain as slightly or much worse compared to their preoperative situation.The question thus rises whether asymptomatic patients should be treated surgicallyat all. A possible answer to this question is given by Fitzgibbons et al. 21 . Their randomizedcontrolled trial showed ‘watchful waiting’ to be an acceptable option for men withminimally symptomatic inguinal hernias. Because of the low incidence of incarceration[1.8/1000 patient-years], delaying surgical repair was considered to be a safe option.In conclusion, the present study shows that pain and long-term functional impairmentaffect a large number of patients after groin herniorrhaphy in a Dutch teaching hospital.Fortunately, much attention is presently drawn to preventive issues of groin pain.Surgeons, however, should set up protocols for recognizing and treating these seriousevents. Additional research on the etiology and treatment of postherniorrhaphy pain isrecommended.APPENDIX QUESTIONNAIRE1 How often did you experience pain in the groin area during the previous month?Never, Occasionally, Regularly, Always2 Please draw an x to indicate the average pain intensity in the operated groin areaduring the past month.VAS: No painUnbearable pain3 Did you ever notice a bulge in the operated groin area during the past month?Yes, No4 Did you notice a numb feeling in the groin, pubic area or the upper leg during the pastmonth?Yes, No5 Are you functionally impaired in daily activities by your complaints?No, Occasionally, Regularly, Always6 What was the average functional impairment during the past month?None, Mild, Moderate, SevereREFERENCES1 Bay-Nielsen M, Perkins FM, Kehlet H. Pain and functional impairment 1 year after inguinalherniorraphy: a nationwide questionnaire study. Ann Surg 2001; 233: 1-72 Callesen T, Bech K, Kehlet H. Prospective study of chronic pain after groin hernia repair. Br J Surg1999; 86: 1528-15313 Poobalan AS, Bruce J, King PM, Chambers WA, Krukowski ZH, Smith WC. Chronic pain andquality of life following open inguinal hernia repair. Br J Surg 2001; 88: 1122-11264 Page B, Paterson D, Young D, O’Dwyer PJ. Pain from primary inguinal hernia and the effect ofrepair on pain. Br J Surg 2002; 89: 1315-13185 Cunningham J, Temple WJ, Mitchell P, Nixon JA, Preshaw RM, Hagen NA. Cooperative herniastudy: pain in the postrepair patient. Ann Surg 1996; 224: 598-6026 Courtney CA, Duffy K, Serpell MG, O’Dwyer PJ. Outcome of patients with severe chronic painfollowing repair of groin hernia. Br J Surg 2002; 89: 1310-13147 Nienhuijs SW, Boelens O, Strobbe LJA. Pain after anterior hernia repair. J Am Coll Surg 2005;200: 885-8898 Liem MSL, Graaf van der Y, Steensel van C, Boelhouwer RU, Clevers GJ, Meijer WS, Stassen LP,Vente JP, Weidema WF, Schrijvers AJ, van Vroonhoven TJ. Comparison of conventional anteriorsurgery and laparoscopic surgery for inguinal hernia repair. N Engl J Med 1997; 336: 1541-15479 Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R Jr, Dunlop D, Gibbs J, Reda D, HendersonW, Veterans Affairs Cooperative Studies Program 456 Investigators. Open mesh versuslaparoscopic mesh repair of inguinal hernia. N Engl J Med 2004; 350: 1819-182726 Chapter 2Chronic sequelae of common elective groin hernia repair 27